Assessment 49 year Pulmonary function No comorbidity Septic shock - PDF document

Case: Mrs S. Assessment ● 49 year Pulmonary function ● No comorbidity ● Septic shock and ARDS after abdominal Maximal exercise testing (incl ECG, respiratory surgery for necrotising appendicitis gas exchange, ventilation) ● ICU admission for 33 days ● ECMO (6 days) – MV (26 days) - CVVH Functional exercise testing ● Status 2 yrs after hospital discharge Muscle testing ● Clinical symptoms: general fatigue, weakness, unemployement, impaired quality of life Quality of life Physical Activity Pulmonary function Quality of Life Lung function Measured % pred ● SF 36 FEV 1 2.11 L 88 ● Physical component: 37 (vs 55 reference population) FVC 2.53 L 90 ● Mental component: 25 (vs 58 reference population) FEV 1 /FVC 83% TLC 3.70 L 81 ● Beck Depression Inventory (II) scale: TLCO 5.03 65 mmol/min/kPa ● Total score 42: severe depression Age 48yr BMI 32,1

Questions? ● Is this patient a good candidate for an exercise training program? ● Are there limitations to perform an exercise training program? Dutch www.fysionet.nl English ● Are you able to prescribe a detailed exercise training www.cebp.nl French program with the present information? www.bvp-sbp.org Portugese EXERCISE TESTING What information is searched for? ● Is the exercise capacity limited (compared to age- matched healthy subjects)? ● Which are the limiting factors? ● Is maximal exertion safe? ● What is the appropriate exercise intensity during training? à Maximal exercise testing!

EXERCISE TEST ● Is the exercise capacity impaired? ● YES (VO 2 peak ~ 75%pred, 15mL/min/kg, 6MWD 62%) Wmax 90 W 92 %pred VO 2 max 1.24 L/min 77 %pred ● Which are the limiting factors? 15,1 ml/kg ● Cardiovascular: (HRmax /HRmaxpred: 151/172 (+/-10)) NO/YES HR 151 min-1 88 %pred ● Ventilatory (VEmax/MVV: 54/79=68%) NO V E 54 L/min 68 %MVV ● Gas exchange limitation (SaO2 rest/exerc 97/97%) NO MVV 79 L/min (37,5x 2.11 (FEV1) ● Muscle weakness (Fatigue score of ´ 7 ´ is indicative, but muscle Sat Rust/max 97/97 % strength tests are needed) Borg 7/8 ● Other? (additional information not from exercise test, Dyspnea/Fatigue- comorbidity?) Exertion 6MWD 335m 62 %pred ● Is maximal exertion safe? (no ECG abnormalities reported) Treatment Muscle Strength Measured % pred ● Which treatment modalities? ● Which modality of exercise training? PImax -124 cm H 2 O 136 ● Strength training? Quadriceps 139 N 35 Handgrip 20 KgF 71 ● Other modalities: respiratory muscle Shoulder Abd 130 N 86 training?

Training schedule FUNCTIONAL ASSESSMENT ● Cycle ergometer (Wmax: 90 Watt): ● Start training intensity (load): 60%Wmax: 55Watt ● Treadmill walking (6MWD: 335m) ● Start training intensity (speed): 75% 3.35km/h: 2.5 km/h ● Stair climbing ● Start training: 2 min at self-selected pace (Borg scale 4-6) ● Resistance training (1RM: 40kg) ● Start training intensity (load): 70%1RM: 28kg) ● Arm crancking ● Respiratory muscle training? WEEK DURATION INTENSITY WEEK DURATION INTENSITY 1 10 min. 75% Speed MWD 1 10 min. 60% Wmax 2 12 min. 75% Speed MWD 2 12 min. 60% Wmax 3 12 min. 80% Speed MWD 3 12 min. 65% Wmax 4 14 min. 80% Speed MWD 4 14 min. 65% Wmax 5 14 min. 85% Speed MWD 5 14 min. 70% Wmax 6 14 min. 85% Speed MWD 6 14 min. 70% Wmax 7 14 min. 90% Speed MWD 7 14 min. 75% Wmax 8 16 min. 90% Speed MWD 8 16 min. 75% Wmax 9 16 min. 95% Speed MWD 9 16 min. 80% Wmax 10 16 min. 100% Speed MWD 10 16 min. 80% Wmax 11 16 min. 100% Speed MWD 11 16 min. 85% Wmax 12 16 min. 110% Speed MWD 12 16 min. 85% Wmax Example Endurance Walking Program Example Endurance Cycling Program

Respiratory muscle training? WEEK INTENSITY SERIES- REPETITIONS. 1 70% 1 R.M. 3 x 8 2 70% 1 R.M 3 x 8 Muscle Strength 3 76% 1 R.M 3 x 8 Measured % pred 4 82% 1 R.M 3 x 8 5 88% 1 R.M 3 x 8 6 94% 1 R.M 3 x 8 PImax -124 cm H 2 O 136 7 100% 1 R.M 3 x 8 Quadr 139 N 35 8 106% 1 R.M 3 x 8 Hand 20 KgF 70 9 112% 1 R.M 3 x 8 Shoulder Abd 130 N 86 10 115% 1 R.M 3 x 8 11 118% 1 R.M 3 x 8 12 121% 1 R.M 3 x 8 Example Peripheral Muscle Resistance Training Program